RECLINER CHAIRS – MANUAL AND ELE

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					RECLINER CHAIRS – MANUAL AND ELECTRIC Criteria for Supply Checklist OBJECTIVE: • To restore, facilitate or maintain an individual’s functional independence and health through the provision of recline chairs, including those: • • • Manually operated (AC09) Electrically operated – recline only (AC06) Electrically operated – recline and lift (AC06)

PLEASE NOTE: Using electric lift recliners may lead to increased dependence and decreased mobility / deconditioning, therefore such equipment should only be provided after careful assessment and trial of alternative seating. Consideration should be given to the need for a maintenance exercise program / Physiotherapy consultation. ASSESSMENT: • • • • • Establish eligibility Complete a home assessment Arrange necessary trial(s) or chair(s) Provide clinical information to Department Arrange any necessary training and advice regarding operation of the chair

CLINICAL CRITERIA There is an assessed need for one of the following: • The Veteran / War Widow has a condition that results in a need to sit in a reclined position. • Leg elevation • There is a need to frequently change positions in a seated position to manage pain levels. • To provide an appropriate appliance for sleeping (when modification to the bed is unsuccessful). In addition to the above, the following criteria must be met before issuing an electric lift recline chair: • There must be a clinically assessed need for electrically assisted sit-stand transfer that cannot be achieved from an appropriate height chair. FUNCTIONAL CRITERIA: • • • Clinical needs cannot be met by current seating or furniture. Clinical needs cannot be met be modifying existing furniture or through the provision of other rehabilitation appliances (e.g. chair raises, high back chairs, leg rests, footstools, cushioning). The person has adequate physical strength and cognitive ability to safely operate recline mechanism.

CHAIRS WILL NOT BE PROVIDED: • • • • • Where the request if for comfort alone. Where existing furniture is in poor condition, contributing to functional difficulties and the individual can manage transfers independently from furniture in good condition. Where there are more appropriate means of managing pain levels e.g. by encouraging the individual to change position from sitting to standing or lying. Where the entitled person does not have adequate strength or cognitive abilities to safely operated the chair. Where the entitled person is a high level care (1 - 4) resident in a residential care facility.

PLEASE NOTE: An electrically operated chair will not be issued if a manually operated recline chair will suffice.
Reviewed April 2002

Manual / Electric Recliner Chair Assessment Form
Department of Veterans’ Affairs
Rehabilitation Appliances Program PO Box 87A Melbourne 3001 Phone: 9284 6870 Fax: 9284 6217 Occupational Therapist Name: Organisation/Provider No. Address: Phone: File No. Card Gold White Date Of Birth: ___/___/___ Surname: Given Name: Address Phone: Please Indicate when available: Monday: Tuesday: am/pm am/pm Thursday: am/pm Friday: am/pm (Please Circle)

Wednesday: am/pm Fax:

Signature:.......................................................................... Source of Referral: Phone: Social Situation: Living in: Comments: House / Unit: L.M.O. Phone: Lives Alone: Retirement Village:

Date: ___/___/___

Accompanied: Hostel:

MAN / ELEC RECLINER CHAIR ASSESSMENT FORM , FEB 2002

Carer’s General Health: (if applicable)

Relevant Medical History / Prognosis:

Manual / Electric Recliner Chair Assessment Form

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Surname:

Given Name:

File No.

Functional Status – Personal ADLs:

Domestic / Community ADLs:

Transfers / Current Seating (including height and condition):

Is veteran / war widow currently driving Can veteran / war widow transfer out of car Mobility (equipment used & distance):

Yes Yes

No No

Upper Limb Function (dexterity, strength, co-ordination): Lower Limb Function (range of movement, strength, balance): Physio Therapy strengthening / maintenance program recieved / arranged? Other comments (e.g. cognition):

MAN / ELEC RECLINER CHAIR ASSESSMENT FORM , FEB 2002

Clinical Justification for Equipment Requested: Identify and describe relevant functional difficulties being experienced: Is existing seating in poor condition and contributing to functional difficulties? Yes No Could veteran / war widow transfer from a chair in good condition Yes No Is existing seating able to be modified? Yes No Comments: Comment on options considered and equipment trialed.

High Backed Chair: Manual Recliner: Electric Recliner: Electric Lift Recliner:
Manual / Electric Recliner Chair Assessment Form

Yes Yes Yes Yes

No No No No
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Surname:

Given Name:

File No.

Clinical Justification (cont): Comments on equipment trialled:

Recommendations:

Reissue Suitable Seating Measurements: Seat Width Seat height: Seat depth: Back height: Additional requirements: cm cm cm cm Hand Controls: Right Manual Recliner: Lever Left

Pushback

Cushioning:
MAN / ELEC RECLINER CHAIR ASSESSMENT FORM , FEB 2002

Back & neck support:

Other: User education completed? Yes No

Please attach quotes on equipment trialled.
Manual / Electric Recliner Chair Assessment Form Page 3


				
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